Provider Demographics
NPI:1255409421
Name:ALTWAL, IYAD W (DDS)
Entity type:Individual
Prefix:
First Name:IYAD
Middle Name:W
Last Name:ALTWAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 SANTA RITA RD APT 11
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-4159
Mailing Address - Country:US
Mailing Address - Phone:925-922-7646
Mailing Address - Fax:
Practice Address - Street 1:678 N WILSON WAY STE D
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4200
Practice Address - Country:US
Practice Address - Phone:209-937-9000
Practice Address - Fax:209-939-1649
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist